Complications associated with cerebral venous thrombosis.

Although CVT is associated with a good outcome in the majority of cases, it may be complicated by numerous unique and sometimes rare complications. The purpose of this review is to discuss the acute and chronic complications of CVT in greater detail. Awareness may lead to a more aggressive approach in those in which these complications are anticipated and perhaps avoided.The complications of CVT may be temporally divided into those unique to the acute stage and those that are associated with the chronic stage of CVT. They are venous infarction and haemorrhage, subarachnoid haemorrhage, a rapid progression and pulmonary embolism. In the chronic stages of CVT, one may encounter dural AV - fistula, progressive psychiatric disease, residual epilepsy and recurrence. Cerebral venous sinus thrombosis is associated with unique acute and chronic complications, some of them may be avoidable e.g. pulmonary embolism. The chronic complications are rare but are potentially treatable e.g. dural AVFistula nidus obliteration with intervention

Incidence and epidemiology of cerebral venous thrombosis.

Cerebral venous sinus thrombosis is a disorder whose epidemiology has changed over the past few decades. It is no longer regarded as a uniformly fatal disease. CVST is not a rare disorder. It may have a differential geographic distribution with a higher incidence in the Asian world. It is a disease of neonates, younger women and men, often a hypercoagulable state, either acquired (e.g., cancer) or a genetic prothrombotic condition may be present. Outcome is not uniformly dismal and prognostic criteria that detect patients with a poor outcome have become available from prospective studies. There is a paucity of well designed large scale epidemiologic studies focused on venous thrombosis from regions where it is relatively frequent (South Asia, Middle East). The newer epidemiologic data derived from a Caucasian database; suggest a better overall prognosis, younger age at distribution than arterial stroke

Mechanical thrombectomy versus intrasinus thrombolysis for cerebral venous sinus thrombosis: a non-randomized comparison.

Small retrospective studies have shown the benefit of endovascular treatment with intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) with/without IST (MT ± IST) in cases of multifocal cerebral venous thrombosis (CVT). Our study compares the mortality, functional outcome and periprocedural complications among patients treated with MT ± IST versus IST alone. We reviewed clinical and angiographic findings of 63 patients with CVT who received endovascular treatment at three tertiary care centers. Primary outcome variables were discharge mortality and neurological dysfunction, and intermediate (three months) and long-term (\u3esix months) morbidity. The modified Rankin scale (mRS) was used to assess morbidity. mRS ≤ 1 was considered a good recovery. Neurological dysfunction was rated as neuroscore: 0, normal; 1, mild (ambulatory, communicative); 2, moderate (non-ambulatory, communicative); and 3, severe (non-ambulatory, non-communicative/comatose). In patients who received IST alone, presenting neurological deficits were comparatively minor (p\u3c0.001). When the two groups were adjusted for admission neuroscore, there was no statistical significance between discharge mortality [7(21%) versus 4(14%), p=0.228], neurological dysfunction (p=0.442), intermediate (p=0.336) and long-term morbidity (p=0.988). Patients who received MT ± IST had a higher percentage of periprocedural complications without reaching statistical significance. Compared to IST, MT was performed in severe cases with extensive sinus involvement. When adjusted for admission neurological dysfunction, both groups had similar mortality and discharge neurological dysfunction and similar intermediate and long-term morbidity

Mechanical Thrombectomy in Cerebral Venous Thrombosis Systematic Review of 185 Cases

Background and Purpose-Cerebral venous thrombosis is generally treated with anticoagulation. However, some patients do not respond to medical therapy and these might benefit from mechanical thrombectomy. The aim of this study was to gain a better understanding of the efficacy and safety of mechanical thrombectomy in patients with cerebral venous thrombosis, by performing a systematic review of the literature. Methods-We identified studies published between January 1995 and February 2014 from PubMed and Ovid. We included all cases of cerebral venous thrombosis in whom mechanical thrombectomy was performed with or without intrasinus thrombolysis. Good outcome was defined as normal or mild neurological deficits at discharge (modified Rankin Scale, 0-2). Secondary outcome variables included periprocedural complications and recanalization rates. Results-Our study included 42 studies (185 patients). Sixty percent of patient had a pretreatment intracerebral hemorrhage and 47% were stuporous or comatose. AngioJet was the most commonly used device (40%). Intrasinus thrombolysis was used in 131 patients (71%). Overall, 156 (84%) patients had a good outcome and 22 (12%) died. Nine (5%) patients had no recanalization, 38 (21%) had partial, and 137 (74%) had near to complete recanalization. The major periprocedural complication was new or increased intracerebral hemorrhage (10%). The use of AngioJet was associated with lower rate of complete recanalization (odds ratio, 0.2; 95% confidence interval, 0.09-0.4) and lower chance of good outcome (odds ratio, 0.5; 95% confidence interval, 0.2-1.0). Conclusions-Our systematic review suggests that mechanical thrombectomy is reasonably safe but controlled studies are required to provide a definitive answer on its efficacy and safety in patients with cerebral venous thrombosi

Endovascular Thrombolysis or Thrombectomy for Cerebral Venous Thrombosis: Study of Nationwide Inpatient Sample 2004-2014

Background and purpose: 15% of cerebral venous thrombosis (CVT) patients have poor outcomes despite anticoagulation. Uncontrolled studies suggest that endovascular approaches may benefit such patients. In this study, we analyze Nationwide Inpatient Sample (NIS) data to evaluate the safety and efficacy of endovascular therapy (ET) versus medical management in CVT. We also examined the yearly trends of ET utilization in the United States. Methods: International Classification of Diseases, Ninth Revision, Clinical Modification codes were utilized to identify CVT patients who received ET. To make the data nationally representative, weights were applied per NIS recommendations. Since ET was not randomly assigned to patients and was likely to be influenced by disease severity, propensity score weighting methods were utilized to correct for this treatment selection bias. Outcome variables included in-hospital mortality and discharge disposition. To determine if our primary outcomes were associated with ET, we used weighted multivariable logistic regression analyses. Results: Of the 49,952 estimated CVT cases, 48,704 (97%) received medical management and 1248 (3%) received ET (mechanical thrombectomy [MT] alone, N = 269 [21%], MT ± thrombolysis, N = 297 [24%], and thrombolysis alone, N = 682 [55%]). Patients who received ET were older with more CVT associated complications including venous infarct, intracranial hemorrhage, coma, seizure, and cerebral edema. There was a significant yearly rise in the use of ET, with a trend favoring MT versus thrombolysis alone. ET was independently associated with an increased risk of death (odds ratio 1.96, 95% confidence interval 1.15-3.32). Conclusions: Patients receiving ET experienced higher mortality after adjusting for age and CVT associated complications. Large, well designed prospective randomized trials are warranted for further evaluation of the safety and efficacy of ETs

A paradoxical relationship between hemoglobin A1C and in-hospital mortality in intracerebral hemorrhage patients.

Objectives:The relationship between prior glycemic status and outcomes in intracerebral hemorrhage (ICH) is not established. We hypothesized that higher hemoglobin (Hb) A1c is associated with worse outcomes in ICH. Patients and methods:Using the GWTG-Stroke registry, data on patients with ICH between April 1, 2003 and September 30, 2015 were harvested. Patients were divided into four ordinal groups based on HbA1c values of <5.7%, 5.7-6.4%, 6.5-8.0% and >8.0%. Outcomes (mortality, modified Rankin Scale (mRS), home discharge and independent ambulatory status) were analyzed for patients overall and separately for patients with or without history of diabetes using multivariable regression models. Results:Among 75,455 patients with ICH (with available HbA1c data), patients with lower HbA1c (<5.7%) had higher rates of in-hospital mortality in the entire cohort (15.5%; 3947/25473); as well as those with history of diabetes (19.0%; 542/2852). Among those without history of diabetes, both lower HbA1c (15.1%; 3405/22621) and higher HbA1c (>8.0%), (15.0%; 205/1364) were associated with higher in-hospital mortality. Lower HbA1c was also associated with higher mRS, less chance of going home, and lower likelihood of having independent ambulatory status in patients with prior history of diabetes. Conclusions:Among patients with no reported history of diabetes, both very low and very high HbA1c were directly associated with higher in-hospital mortality. Only very low HbA1c was associated with higher mortality in known diabetic patients. Further studies are needed to better define the relationship between HbA1c and outcomes, for it may have important implications for care of ICH patients

Endovascular Management of Symptomatic Extracranial Stenosis Associated with Secondary Intracranial Tandem Stenosis. A multicenter review.

BACKGROUND: Several studies have reported variable rates of perioperative risk of stroke in individuals with tandem stenoses after carotid endarterectomy. Endovascular treatment of extracranial lesions associated with tandem lesions is limited to case reports and small case series. METHODS: We retrospectively reviewed clinical records and angiographic findings of 132 symptomatic patients with extracranial atherosclerotic disease who underwent elective stent placement at three tertiary care centers. Tandem stenosis was defined as any lesion with intracranial stenosis ≥50% in the same (but not contiguous) vascular distribution distal to primary extracranial stenosis. The study end point was a composite of any stroke or death within 24 hours, at 1- and 6-month postprocedure. The rates of primary end points were compared between patients with or without secondary tandem stenosis. RESULTS: Out of 132 patients (134 procedures), 27 patients were identified with a tandem stenosis. The stroke and/or death rates at 24 hours were (11.1% vs 7.5%, P = . 69) for patients with tandem stenosis and single stenosis, respectively. The cumulative stroke and/or death rate at 1-month postprocedure (15.0% vs 7.5%, P = .10) and at 6-month postprocedure (26.6% vs 12.8%, P = .08) appeared to be higher among those with tandem stenoses without reaching statistical significance. CONCLUSIONS: The high risk of postprocedural stroke and/or death observed in this series requires careful assessment of the risk/benefit ratio of endovascular procedures in patients with tandem stenosis

External Validation of Atherosclerotic Neuroimaging Biomarkers in Emergent Large‐Vessel Occlusion

Background Intracranial atherosclerosis related large vessel occlusion (ICAS‐LVO) is the major cause of failed mechanical thrombectomy. ICAS‐LVO causes reocclusion or a fixed focal stenosis, leading to suboptimal revascularization and poor functional outcomes. We aimed to externally validate 4 preidentified imaging biomarkers of ICAS‐LVO: absent hyperdense sign, Hounsfield units (Hu ratio ≤1.1 and Delta Hu <6) and truncal‐type occlusion, observed on admission noncontrast computed tomography and computed tomography angiography in patients presenting with emergent large‐vessel occlusion (ELVO). Methods We conducted a retrospective cohort observational study of consecutive patients presenting with acute M1/terminal internal carotid artery occlusions undergoing mechanical thrombectomy. Inability to locate a hyperdense vessel on noncontrast computed tomography at the corresponding ELVO on computed tomography angiography was labeled absent hyperdense sign. Delta Hu and Hu ratio were defined as the difference and ratio of the Hu of the ELVO on noncontrast computed tomography and its mirror contralateral patent vessel, respectively. ELVO was classified as truncal‐type occlusion if the bifurcation distal to the occlusion was spared on computed tomography angiography. ICAS‐LVO was defined as the presence of fixed focal stenosis or reocclusion after mechanical thrombectomy. Statistical analysis was performed using C statistics, receiver operating characteristic curve analysis, and multivariate logistic regression. Results Of 161 patients, 30 (18.6%) had suspected ICAS‐LVO. Absent hyperdense sign had a sensitivity of 90% and specificity of 87% (area under the curve [AUC], 0.88), in predicting ICAS‐LVO. Hu ratio ≤1.1 (AUC, 0.89) and Delta Hu <6 (AUC, 0.96) had sensitivity of 100% and 97% and specificity of 79% and 95%, respectively. Truncal‐type occlusion showed a sensitivity of 75% and specificity of 98% (AUC, 0.87). When comparing receiver operating characteristic AUC, Delta Hu <6 was significantly better than absent hyperdense sign (P=0.006); Hu ratio ≤1.1 (P=0.006); and truncal‐type occlusion (P=0.02). Conclusion Combination of neuroimaging biomarkers using noncontrast computed tomography and computed tomography angiography in ELVO identify ICAS‐LVO with high predictive power. Larger, prospective, multicenter studies are warranted to further evaluate their effectiveness in diagnosing ICAS‐LVO